How To Get A Disability Check From A Health Insurance Company

Transcription

1 INSURED'S ADDRESS (Home Address) Leaders Life Insurance Company Bloomfield, CT (888) PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF YOUR CLAIM. INSTRUCTIONS: INSURED: COMPLETE PART I, SIGN AND DATE THE AUTHORIZATION FOR RELEASE OF INFORMATION, THE FRAUD STATEMENT, AND THE CLAIMANT'S OCCUPATIONAL DESCRIPTION. HAVE YOUR PHYSICIAN COMPLETE PART II AND YOUR EMPLOYER COMPLETE PARTIII AND RETURN ALL DOCUMENTS TO THE CLAIM ADMINISTRATOR. MAIL TO: Leaders Life Insurance Company,, P. O. Box 86, Bloomfield, CT or FAX to (with originals to follow) PART I -- INSURED'S STATEMENT POLICY NUMBER NAME OF INSURED DATE OF BIRTH / / CITY MALE FEMALE MARITAL STATUS SINGLE MARRIED STATE ZIP CODE DIVORCED WIDOW(ER) INSURED'S ADDRESS (Mailing address if different) CITY STATE ZIP CODE SOCIAL SECURITY NUMBER TELEPHONE NUMBER NAME OF EMPLOYER EMPLOYER'S ADDRESS EMPLOYER TELEPHONE NUMBER CITY STATE ZIP CODE THE BUSINESS ENTITY IS A CORPORATION SUB CHAPTER S (if self-employed) PARTNERSHIP SOLE PROPRIETORSHIP OCCUPATION WHAT IS YOUR OWNERSHIP PERCENTAGE? % SPECIALTY (if applicable) WEEKLY EARNED INCOME AT THE TIME YOUR TOTAL DISABILITY BEGAN: GROSS NET (Please submit most recent pay stub) $ $ AVERAGE WEEKLY EARNED INCOME DURING THE TWO YEARS JUST PRIOR TO DISABILITY: $ $ (Please submit personal and business tax returns for the applicable years with all supporting attachments and schedules) DATE ACCIDENT OR SICKNESS BEGAN DATE LAST WORKED DATE FIRST TREATED BY PHYSICIAN FOR PRESENT DISABILITY NATURE OF SICKNESS OR INJURY DID DISABILITY ARISE OUT OF EMPLOYMENT? YES NO IF INJURED, HOW, WHEN AND WHERE DID THE ACCIDENT HAPPEN? (Please include a copy of any police or incident report) DATE TOTAL DISABILITY COMMENCED IF RECOVERED, GIVE DATE OF RECOVERY DATE OF YOUR RETURN TO WORK FULL TIME / / ( ) HOURS PER DAY PART TIME / / ( ) HOURS PER DAY NAME AND ADDRESS OF ALL PHYSICIANS AND/OR FACILITIES TREATING YOU FOR THIS CONDITION (Attach additional sheet of paper if necessary) HAVE YOU APPLIED AND/OR ARE YOU ENTITLED TO BENEFITS FROM ANY OF THE FOLLOWING FOR THIS DISABILITY? WORKERS' COMPENSATION ANY GOVERNMENT AGENCY OTHER INSURANCE BENEFITS SOCIAL SECURITY LOCAL, STATE, OR NATIONAL ASSOCIATION OR SOCIETY DISABILITY INCOME PLAN SALARY CONTINUANCE NONE IF "YES", LIST POLICY NUMBER, NAME AND ADDRESS OF INSURANCE COMPANY OR ORGANIZATION PROVIDING SUCH BENEFITS OR SERVICES AND AMOUNT OF PAYMENT. POLICY NUMBER NAME, ADDRESS AND PHONE NUMBER DATE OF APPLICATION AMOUNT OF PAYMENT $ POLICY NUMBER NAME, ADDRESS AND PHONE NUMBER DATE OF APPLICATION AMOUNT OF PAYMENT $ I HEREBY CERITFY THAT THE ANSWERS I HAVE MADE TO THE FOREGOING QUESTIONS ARE BOTH COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF INSURED DATE LDR Part I

2 PART II -- ATTENDING PHYSICIANS'S STATEMENT (attach additional pages as needed) (TO BE COMPLETED BY PHYSICIAN WITHOUT EXPENSE TO THE COMPANY NAME OF PATIENT HEIGHT WEIGHT BLOOD PRESSURE / DATE OF BIRTH HISTORY When did symptoms first appear or accident happen?... Mo. Day Year Date patient was unable to work because of disability?... Mo. Day Year Has patient ever had same or similar condition?... Yes No If Yes, when? Mo. Day Year Pregnancy? Yes No If "Yes", what is the estimated date of delivery? Actual date of delivery? Names and addresses of other treating physicians DIAGNOSIS (including any complications) _ Subjective symptoms Objective findings (including current X-rays, EKG's, Laboratory Data, and any clinical findings) DATES OF TREATMENT Date of first visit / / Date of last visit / / Date of next visit / / NATURE OF TREATMENT (Include surgery, date and description, and medications prescribed, if any) PROGRESS Patient has... Recovered Improved Unchanged Retrogressed Patient is... Ambulatory House Confined Bed Confined Hospital Confined Has patient been hospital confined? Yes No If Yes, Name of Hospital Address Confined from through CARDIAC (If applicable) Functional Capacity (American Heart Association) Class 1 (No Limitation) Class 2 (Slight Limitation) Class 3 (Marked Limitation) Class 4 (Complete Limitation) Blood Pressure / as of date PHYSICAL IMPAIRMENT (*as defined in Federal Dictionary of Occupation Titles) Class 1 -- No Limitation of functional capacity; capable of heavy work.* No restrictions. (0 --10%) Class 2 -- Medium limitation of function capacity; manual activity. * ( %) Class 3 -- Slight limitation of functional capacity; capable of light work.* ( %) Class 4 -- Moderate limitation of functional capacity; capable of clerical./administrative (sedentary*) activity. ( %) Class 5 -- Severe limitation of functional capacity; incapable of minimal (sedentary*) activity. ( %) MENTAL/NERVOUS IMPAIRMENT Class 1 -- Patient is able to function under stress and engage in interpersonal relations. (no limitations) Class 2 -- Patient is able to function in most stress situations and engage in most interpersonal relations. (slight limitations) Class 3 -- Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations. (moderate limitations) Class 4 -- Patient is unable to engage in stress situations or engage in interpersonal relations. (marked limitations) Class 5 -- Patient has significant loss of psychological, personal and social adjustment. (severe limitations) COMPETENCY Do you believe the patient is competent to endorse checks and direct the use of the proceeds thereof? Yes No PROGNOSIS What are the patient's restrictions and limitations? PATIENT'S JOB If no restrictions and limitations, when was patient able to resume work? Mo. Day Year ANY OTHER WORK Mo. Day Year Do you expect a fundamental or marked change in the future including improvement and/or deterioration?... Yes No Yes No When will patient recover sufficiently to perform duties?... 1 Month 1-3 Months 1 Month 1-3 Months. 3-6 Months Indefinitely 3-6 Months Indefinitely Never Never ADDITIONAL CARE Have you referred your patient for other types of consultation? Yes No If Yes, Name and Address: Specialty: I HEREBY CERITFY THAT THE ANSWERS I HAVE MADE TO THE FOREGOING QUESTIONS ARE BOTH COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. NAME OF PHYSICIAN COMPLETING THIS FORM (PRINT) DEGREE/SPECIALTY TAX ID NUMBER ADDRESS TELEPHONE NUMBER SIGNATURE OF PHYSICIAN COMPLETING THIS FORM CITY STATE ZIP CODE FAX NUMBER DATE PLEASE RETURN THIS FORM TO THE INSURED OR THE ADMINISTRATOR LDR Part II

3 PART III -- EMPLOYER'S STATEMENT (attach additional pages as needed) PLEASE PROVIDE A COPY OF THE OCCUPATIONAL DESCRIPTION APPLICABLE TO EMPLOYEE NAME OF EMPLOYEE OCCUPATION IS DISABILITY DUE TO EMPLOYMENT? Yes No AVERAGE NUMBER OF HOURS WORKED PER WEEK SALARY Gross Net Weekly earned income at time disability began $ $ Average weekly earned income for two years prior to the date of disability $ $ DATE EMPLOYED DATE INSURED DATE RETURNED TO WORK DATE LAST WORKED FULL-TIME PART-TIME NUMBER OF HOURS REASON FOR STOPPING WORK Effective Date Dismissed Lv of Absence Disability Resigned Retired Layoff IF EMPLOYEE HAS NOT RETURNED TO WORK, APPROXIMATE RETURN TO WORK DATE DATE EMPLOYMENT TERMINATED WERE THERE ANY CHANGES TO THE EMPLOYEE S JOB RESPONSIBILITIES DUE TO THE DISABLING CONDITION BEFORE THE EMPLOYEE BECAME TOTALLY DISABLED? Yes No IF YES, WHAT WERE THE CHANGES AND WHEN WERE THEY MADE? IS THIS EMPLOYEE ELIGIBLE FOR SALARY CONTINUATION? Yes No Please include a copy of applicable payroll record(s) IF YES, WHAT IS THE WEEKLY AMOUNT? $ WHEN DO BENEFITS BEGIN? / / END? / / CHECK THE ITEMS BELOW THAT RELATE TO THE EMPLOYEE S JOB AND COMPLETE THE INFORMATION REQUESTED. USE THESE DEFINITIONS FOR THE FREQUENCY OF OCCURRENCE: Not applicable means the person does not perform this activity. Occasionally means the person does the activity up to 33% of the time. Frequently means the person does the activity 34% to 66% of the time. Continuously means the person does the activity 67% to 100% of the time. Activity N/A Occasionally Frequently Continuously Standing Walking Balancing Stooping Kneeling Crouching Crawling Reaching/working overhead Keyboard Use/Repetitive Hand Motion Climbing Activity Frequency Weight o PUSHING LBS. o PULLING LBS. o LIFTING LBS. o CARRYING LBS. I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE STATEMENTS ARE TRUE AND CORRECT. NAME OF POLICYHOLDER (COMPANY) PRINT NAME &TITLE OF OFFICAL REPRESENTATIVE MAILING ADDRESS OF POLICYHOLDER (COMPANY) SIGNATURE TELEPHONE NUMBER FAX NUMBER DATE PLEASE RETURN THIS FORM TO LEADERS LIFE INSURANCE COMPANY,, Bloomfield, CT LDR III

4 Leaders Life Insurance Company Bloomfield, CT (888) Authorization for Release of Information HIPAA Compliant CLAIMANT'S NAME DATE OF BIRTH SOCIAL SECURITY NUMBER I hereby authorize all of the people and organizations listed below to give Leaders Life Insurance Company and its authorized representatives, including agents and insurance support organizations, (collectively, the "Recipient"), the following information: any and all information documents, treatment notes (including psychotherapy notes), consultation notes, and reports of diagnostic procedures relating to my health and my insurance policies and claims, including, but not limited to, information relating to any medical consultations, treatments, or surgeries; hospital confinements for physical and mental conditions; use of drugs or alcohol; and communicable diseases including HIV or AIDS. any and all information relating to my occupation, my employment, or my activities. I hereby authorize each of the following entities to provide the information outlined above: any physician or medical practitioner; any hospital, clinic or other health care facility any insurance or reinsurance company (including, but not limited to, the Recipient) any consumer reporting agency or insurance support organization; my employer, group policyholder, or benefit plan administrator; and the Medical Information Bureau (MIB); and any other person or business. I understand that the information obtained will be used by the Recipient to: determine my eligibility for coverage and/or benefits under an insurance policy; and detect insurance fraud or abuse or for compliance activities, which may include disclosure to MIB and participation in MIB's fraud prevention or fraud detection programs. I hereby acknowledge that the insurance company listed above is subject to federal privacy regulations. I understand that information released to the Recipient will be used and disclosed as described in the Leaders Life Insurance Company's Information Privacy Practices, but that upon disclosure to any person or organization that is not a health plan or health care provider, the information may no longer be protected by federal privacy regulations. I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization or other law allows the Recipient to contest a claim under the policy or to contest the policy itself, by sending a written request to: Leaders Life Insurance Company, P. O. Box 86, Bloomfield, CT I understand that my revocation of this authorization will not affect prior uses and disclosure of my health information by the Recipient for purposes of claims administration and other matters associated with my claim for benefits under insurance coverage and the administration of any such policy. I understand that the signing of this authorization is voluntary; however, if I do not sign the authorization, the Recipient may not be able to obtain the information necessary to consider my claim for benefits. I further understand an investigative consumer report may be requested concerning factors affecting my eligibility for insurance benefits. The factors which may be investigated include my activities, personal characteristics, mode of living, and health history. The report may be obtained through personal interviews with my friends, neighbors, and associates. I have a right to submit a written request to you for a complete and accurate disclosure of the nature and scope of any such report. This authorization will be valid for 24 months or the duration of any claim for benefits under my insurance coverage, whichever is later. A copy of this authorization will be as valid as the original. I understand that I am entitled to receive a copy of this authorization. Name of Claimant (print) Signature of Claimant/Guardian/Representative LDR Release Date Description of Authority of Personal Representative (if applicable)

5 Leaders Life Insurance Company Bloomfield, CT (888) Fraud Statement FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW: Any person who knowingly, and with intent to defraud any insurance company, files or causes to be filed, a claim for payment of a loss, containing any false or incomplete information commits a fraudulent insurance act that may be a crime and may subject such person to incarceration, fines, and denial of benefits. ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilt of a felony of the third degree. KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud an insured: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law. PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation. Signature of Insured Date LDR FRAUD

6 Leaders Life Insurance Company Bloomfield, CT (888) Claimant's Occupational Description Important: This form should be completed as fully as possible with respect to your work immediately prior to your claimed date of disability. NAME OF INSURED SOCIAL SECURITY NUMBER DATE OF BIRTH EMPLOYER NAME EMPLOYER'S ADDRESS (City, State, Zip) EMPLOYER'S TELEPHONE NUMBER NAME OF SUPERVISOR YRS. WITH EMPLOYER LAST DAY WORKED IF OWNER, PERCENTAGE OWNERSHIP HRS. WORKED PER WEEK USUAL DAYS WORKED S M T W T F S USUAL DAILY HOURS From : To: AVERAGE WEEKLY SALARY $ YEARS IN OCCUPATION OCCUPATION TITLE(S) A. Occupational Duties and Activities (List the most important first) Hrs. per % of Week Time 1. Duty Description 2. Duty Description 3. Duty Description 4. Duty Description B. Instruments, Tools or Equipment Normally used in Your Occupation: C. Where Do You Work? Mostly Indoors Mostly Outdoors Equally In and Out D. Travel (If your occupation normally requires travel other than between residence and principal place of business, describe usual frequency, mode of travel, trip distance and purpose.) E. Professional Affiliations, Licenses, and Certifications (i.e. Trade Memberships, Associations): Licenses and Certifications (Include License and/or Certification No.): NAME OF CLAIMANT (PRINT) SIGNATURE OF CLAIMANT/GUARDIAN/REPRESENTATIVE DATE LDR OCCDESC